CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Actimmune 2375 A Sgm P2022

Defines covered indications, prescriber specialty requirements, authorization durations, continuation criteria, and compendial use for Actimmune. Experimental/investigational uses outside listed indications are not covered.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyActimmune 2375 A Sgm P2022

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionAuthorization of up to 12 months may be granted for initial therapy for covered indications (CGD, SMO, mycosis fungoides/Sezary syndrome) and for continuation when member shows disease stability or improvement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

3Covered Indications

1Compendial Indication (MF/Sezary)

Coverage Summary

Covered indications: Actimmune (interferon gamma-1b) is covered for chronic granulomatous disease (CGD) to reduce the frequency and severity of serious infections, and for severe malignant osteopetrosis (SMO) to delay time to disease progression. The policy also allows compendial use for mycosis fungoides/Sezary syndrome.

Authorization duration: Authorization of up to 12 months may be granted for each covered indication (initial therapy).

Initial Therapy Criteria (Medically Necessary - Covered Indications)

Medically Necessary - Covered Indications

Authorization of 12 months may be granted when ALL of the following are met for each indication:

ALL of the following

Indication is one of the following covered uses: chronic granulomatous disease (CGD), severe malignant osteopetrosis (SMO), or mycosis fungoides/Sezary syndrome (compendial).
Specialist by indication
- For CGD: immunologist or prescriber who specializes in the management of CGD.
- For SMO: endocrinologist.
- For Mycosis Fungoides/Sezary Syndrome: hematologist or oncologist.

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title": "Medically Necessary - Covered Indications"

ref": "b1_0"

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Provider Actions

Prior Authorization

Authorization requirement

Authorization of up to 12 months may be granted for initial therapy for covered indications (chronic granulomatous disease, severe malignant osteopetrosis, or mycosis fungoides/Sezary syndrome). Authorization of up to 12 months may also be granted for continuation of therapy when the member is receiving Actimmune for a listed indication and is experiencing benefit from therapy as evidenced by disease stability or disease improvement.

Documentation Required

Prescriber specialty documentation

This medication must be prescribed by or in consultation with an appropriate specialist for the indication. For chronic granulomatous disease, the prescriber should be an immunologist or a clinician who specializes in CGD. For severe malignant osteopetrosis, the prescriber should be an endocrinologist. For mycosis fungoides/Sezary syndrome, the prescriber should be a hematologist or oncologist.

Background

FDA-approved indications: Actimmune is indicated to reduce the frequency and severity of serious infections in chronic granulomatous disease (CGD) and to delay time to disease progression in severe, malignant osteopetrosis (SMO).

Compendial allowance: Use for mycosis fungoides/Sezary syndrome is listed as a compendial (allowed) indication.

Continuation: Authorization renewal (up to 12 months) requires documentation that the member is experiencing benefit from therapy evidenced by disease stability or disease improvement.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyActimmune 2375 A Sgm P2022

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Actimmune 2375 A Sgm P2022

Coverage Summary

Initial Therapy Criteria (Medically Necessary - Covered Indications)

Continuation Therapy Criteria

Not Medically Necessary / Experimental or Investigational

Provider Actions

Applicable Codes

Clinical Evidence & References

Background